Provider Demographics
NPI:1336260645
Name:MITHAL, MANOJ (MD)
Entity Type:Individual
Prefix:
First Name:MANOJ
Middle Name:
Last Name:MITHAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 S HEALTH PKWY
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-8352
Mailing Address - Country:US
Mailing Address - Phone:269-273-9789
Mailing Address - Fax:269-273-9611
Practice Address - Street 1:715 S HEALTH PKWY
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-8352
Practice Address - Country:US
Practice Address - Phone:269-273-8471
Practice Address - Fax:269-273-9680
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088958208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700G560080OtherBCBS GROUP-THREE RIVERS HEALTH
MI1336260645Medicaid
MI46525OtherHEALTH PLAN OF MICHIGAN
2507510592OtherBCBS PIN
382317300011OtherTRICARE
2507510592OtherBCBS PIN
MI1336260645Medicaid
MI700G560080OtherBCBS GROUP-THREE RIVERS HEALTH
MI23U015Medicare Oscar/Certification
MI46525OtherHEALTH PLAN OF MICHIGAN